During the pandemic’s darkest days, some of the medical staff who serve the Navajo Nation were caring for their own family members, said Dr. Maricruz Merino.
Merino is chief of internal medicine at Gallup Indian Medical Center in Gallup, New Mexico. Recalling the early days of the pandemic, she said, “I personally did not know if I was going to survive the year and if my family members or staff were going to get sick, or have lifelong consequences, or lose their lives.”
In the Navajo Nation, defined by close community bonds and a strong collective identity, medical staff confronted the same challenges that doctors and nurses all over the world have faced – along with the difficulty of watching Covid-19 strike the Navajo community.
“I lost many, many primary care patients…just tremendously beautiful human beings who were lost to Covid,” said Dr. Mia Lozada, who practices internal medicine and is a medical officer at Gallup Indian Medical Center. “It’s never easy to lose primary care patients…much less in this way that feels so unfair and that is dominoed by loss after loss after loss.”
There’s no question that the sovereign Nation, which spans 27,000 square miles across parts of Arizona, New Mexico, and Utah, knows what it’s like to feel devastated by Covid-19. According to the Navajo Times, the death toll stands at 1,293 out of approximately 30,000 cases – a significantly higher rate than the United States average. Many elders, revered sources of knowledge and language, lost their lives to the disease. The community has yet to fully come to terms with its grief, said Dr. Jonathan Iralu, the infectious disease consultant for the Indian Health Service and the Navajo Area.
But despite the dangers and difficulties, the Nation’s leaders launched a full-scale effort to combat the disease – and evidence suggests that the work has paid off. New cases have slowed significantly, to an average of 15 per day as of May 17, according to the Navajo Times.
Their success is the result of strong leadership on vaccine distribution and administration – 93.5% of the Nation’s eligible population had received at least one shot as of May 12, far surpassing vaccination rates in the United States – and their comprehensive prevention measures, including mask-wearing, screenings, and curfews.
And doctors who have gone to extraordinary measures over the past year to care for their community are able to take a deep breath.
“It’s palpably different than how it was a year ago, three months ago,” Lozada said.
Looking back on the past year, Merino recalled that “we had to completely let go of any notions about what our job descriptions were and become very creative.” Fortunately, she said hospital leadership recognized the seriousness of the situation immediately and acted accordingly.
Providers quickly swung into action, implementing outdoor Covid-19 screening and testing before doing so was a widespread practice, starting a hotel isolation program for people awaiting test results, providing drive-up pharmacy services, and reassigning various department to “non-traditional roles to support inpatient care and support activities,” said Dr. Kimberly Mohs, medical director of the Health Education Center for Wellness at the Northern Navajo Medical Center in Shiprock, New Mexico.
Mohs explained that a high priority was increasing the number of patients they could treat at the hospital, “to enable us to keep more of our patients at our facility, close to their home, relatives, and primary providers.”
According to Merino, as Navajo Nation doctors practice in a rural area with relatively few sub-specialists on staff, “our scope of practice is broader than it might otherwise be” even during non-emergency times – in other words, physicians take on more and broader responsibilities than they might in an urban setting.
During the early days of Covid-19, that was more the case than ever. “No one was a subspecialist in Covid, and it really felt like we were more alone than usual, and really had to rely on ourselves,” Merino said. “As the year went on, and people had more experience in outside institutions, what we found was everyone was doing things differently.”
At one point, Merino recalled, her hospital was intubating a patient or two every day – normally an extremely rare occurrence.
The difficulties weren’t just in treating Covid-19 itself. In addition, providers were working to source PPE, make the most effective use of limited testing supplies, and taking steps to suppress outbreaks in the community. “You have people wearing five or six hats,” she said.
To support doctors serving the Navajo Nation as they fought the pandemic, collaborators, such as Brigham and Women’s Outreach Program with Indian Health Service, provided consultants who specialized in infectious diseases and critical care, Mohs said, as well as helping to meet medical supply and PPE shortages. (Direct Relief has provided support both directly to the Navajo Nation and through collaborators and partners.)
“I’m getting to see my patients”
As it did all over the world, Covid-19 has affected other kinds of health care, such as chronic disease management and treatment, as well. “There are over 1,000 diabetic patients that did not come for care over the past year,” Mohs said.
For Lozada, too, the pandemic has meant seeing patients who had previously had well-controlled chronic conditions “and now for the first time, they’re very uncontrolled, for a variety of reasons.”
As the pandemic has quieted, that’s beginning to change, Iralu said. Primary care visits are beginning to take place in person again, and there’s been an increased demand for the kind of services the hospitals provided all along.
“In the HIV clinic, I’m getting to see my patients I have not seen in ages, and it’s just wonderful,” he said. “You really miss out on that human, person-to-person interaction when you’re just talking over the telephone.”
“Once the [Covid-19] wave calmed down a little bit, the wave in primary care came on top of us,” Merino said. “And that felt overwhelming as well…from the frying pan to the fire.”
“I wouldn’t trade being here”
Like providers around the world, the doctors interviewed said that mental health and exhaustion were still in the process of being addressed.
Iralu sees two interconnected consequences of the pandemic: one related to physical symptoms, the other to community grief. “Both are going to occupy our attention and time.”
Mental health concerns related to the pandemic have affected community members and providers alike. “We’re starting to contend with feelings that we had bottled up just to get through the day…We’re starting to process what we’ve been through,” Merino said.
“I don’t know if all of us have emotionally had enough space to process what’s been going on in the last year,” said Lozada. “I think it’s going to take a lot longer…to be able to take in what’s really happened to our community in this last year.”
Most recently, through a grant made by Together Rising, Direct Relief supported the Navajo Nation Department of Health and Brigham and Women’s Outreach Program in their work providing a variety of in-person and virtual mental health support to hospital staff and other frontline workers in the Nation.
Sitting in on peer support groups, Merino said, has been eye-opening. “I thought I knew what people were going through to some extent because I was there, I lived through it, too, but everybody’s experience is very different,” she said.
Part of that mental health support has included traditional Navajo healers, who have conducted rituals and prayers to address the pandemic’s effects. “Native blessings and healing rituals have been vital to staff morale over both surges,” Mohs said. After a valued traditional healer died of Covid-19, “we were fortunate to find a medicine man to help with staff prayers, blessings, smudging, and traditional grief counseling.”
Lozada, too, spoke of the importance of traditional medicine. She offered the example of a medicine woman who blessed herbs that were then offered to people isolating in hotels. “I was so, so struck by the number of individuals who valued that offering…That was such an important part of their healing process,” she said. “I think there’s a huge role for native healing to work here in conjunction with the way I was trained to heal an individual.”
Despite the challenges, Lozada said, she values the sense of community she experienced during the pandemic, and the opportunity to provide vital care.
“I wouldn’t trade being here for anything,” she said.
Since the beginning of the pandemic, Direct Relief has provided over $1 million in financial assistance and over seven tons of medicines and supplies to the Navajo Nation Tribal health system. All Direct Relief donations, whether financial or medical, were made in consultation with Tribal leadership in advance, and directly supported the operations of the Navajo Nation Department of Health, the Fort Defiance Indian Hospital Board, Brigham and Women’s Outreach Program with Indian Health Service, and Community Outreach and Patient Empowerment (COPE).
Medical aid, including PPE and Covid-related supplies, was sent to Navajo Nation Health Command Center at Chinle, Northern Navajo Medical Center, Gallup Indian Medical Center, Tséhootsooí Medical Center at Fort Defiance, United Natives Health Program, the Diné Hatathlie Association, and Navajo Nation schools.
Direct Relief’s supporter, Together Rising, made an additional financial contribution of $365,000 specifically to address the mental health needs of Tribal health care workers and support traditional healing.